14:21 PM

Insurance Claim Appeals 101


If you feel your case deserves another look, here’s what to know.

In life, we learn quickly to expect the unexpected. That’s a big reason why we buy health insurance. But what if your policy doesn’t cover something you expected it to, and you need to file an appeal?

Fortunately, that’s a rare event. But it does happen. And if it happens to you, it’s a big deal.

Our appeals process makes sure coverage decisions are based on the facts. We look at the facts about your specific insurance policy, your claim and the current medical evidence and standards.

Most Common Reason: Incomplete or inaccurate information

A claim or bill can be denied because of an error. Someone in the doctor’s office, someone at Horizon, or you may not have provided all the information Horizon needs to approve a claim or may have filed an incorrect claim. If you get an Explanation of Benefits from Horizon that says a claim was denied or a bill from a provider for something you are pretty sure was covered, contact Horizon customer service. We’ll look at the claim and try to find the error, if your doctor's office made one, and work with you and your doctor so they resubmit the claim with the right information. Unfortunately, Horizon cannot correct an error - only a provider can submit or correct a claim.

Treatment not covered

But what if everyone involved followed the correct procedures, submitted the right information and your claim was still denied? There are several reasons that might occur – it may be that the procedure or treatment is not covered by your policy, is not approved for your condition, or is only covered when delivered in a certain setting or by a certain kind of provider.

For example, let’s say you have shoulder pain and go to a massage therapist because you know physical therapy is covered. While the massage is a covered benefit, it is likely only covered when the service is administered by a licensed physical therapist, but not when administered by a massage therapist. That is an instance in which you would not be able to appeal.

The details of exactly what is covered are in your policy. Sign in to your Member Online Services account and visit the “Benefits & Coverage” section to can learn what’s covered and what’s not. If you still have questions, give us a call.

Most of the time, your doctor and Horizon will agree on your treatment. The medical policies that spell out standards of care and what constitutes high quality, effective, and efficient care are generally agreed upon by the majority of medical professionals. But sometimes a doctor believes you need a treatment that is not covered. In those instances, you can – with the help of your doctor – appeal a coverage decision. 

The Appeals:  Three Sets of Eyes

All parties involved in the appeal process have rights and responsibilities under State and Federal law. The appeals process is a system of checks and balances that is transparent and relies on facts to ensure that everyone is treated fairly.

A first level appeal is conducted by our medical staff, often with input from a specialist in the same field as your doctor. If you are not satisfied with their determination, then you can ask for second level appeal that goes to our Member Appeals Committee (MAC)– a group of consumer advocates and Horizon representatives who examine all of the information provided by you, your doctor, and Horizon’s medical experts. 

If you disagree with their second level appeal decision, you can ask for a review by an independent, outside medical expert  (called an IURO – short for Independent Utilization Review Organization) authorized by the NJ Department of Banking and Insurance. The IURO review is final and its decisions must be followed by all parties.  

Forms for an appeal can be found here, but you will always be provided clear and simple guidance about how to file an appeal when you are notified that a claim or advanced authorization has not been approved. If you’re considering an appeal, we recommend you use our Appeals Checklist as you navigate the process. Your doctors also play a critical role in medical appeals, so it will be important to work with them.

Appeal rights, levels, and filing deadlines can be different depending on your specific health plan. Either way, we’re always here to help guide you through the process and help ensure that you are getting the most from your health insurance plan.